Ongoing Services

- Cavity-Free at Three Statewide Training
- How to refer children with developmental delays
- Provider Resource Helpline Helps Your Special Needs Children: Identify & Access All Resources and Care Coordination
- Medical Home Certification
- Post-partum Depression Screening
- Practice Manager's Meeting May 11, 11:30 to 1:00 PM @ TCH, RSVP carter.joyce@tchden.org
- Announcing an Interactive Cross-Cultural Communications Website Designed Especially for Healthcare Professionals
- Introducing the CCHAP Quick Reference Link
- Child Psychiatry Telephone Consultation on Medicaid Children
- Integrating Developmental Screening In a Pediatric Practice
- Medical Spanish Training For Your Office Staff
- Child Psychiatrist Available to Provide Conferences for You In your Office
- Language as a Communication Barrier in Medical Care for Hispanic Patients Plus A Spanish Course For Providers

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Health Reform for Children
The Affordable Care Act Gives
Parents Greater Control Over Their Children’s Health Care.
Quality, Affordable Health Care for All Children

This is the official summary from the White House

• Eliminates Pre-existing Coverage Exclusions for Children
  - This year, prohibits health insurers from excluding coverage of children because of preexisting conditions.
•  Extends the Children’s Health Insurance Program
  - Extends federal funding for the Children’s Health Insurance Program (CHIP) through September 30, 2015, and provides states with additional funding to ensure children have access to this proven successful program. Increases outreach and enrollment grants to help reach more eligible children.
• Pediatric Benefit Package Includes Oral and Vision Coverage for all Children
  - Requires coverage of not only basic pediatric services under all new health plans, but also oral and vision needs, starting in 2014. Many health plans do not provide coverage for needed child health services, and 12 percent of children have not had a doctor’s visit in the past year.
• More Pediatric Providers Where Kids Need Them
  - Expands the health care workforce – including pediatricians, pediatric nurse practitioners, specialists in pediatrics, and pediatric oral health professionals – to ensure that children will have access to high quality health care. This year, requires that parents enrolled in new plans be allowed to select their child’s pediatrician from among any participating provider.
• Improve Quality of Care for Children
  - Develops children’s quality priorities and promote children’s quality measurement and reporting to improve the care that our nation’s  children receive. A recent study found that children receive recommended care less than half of the time.
• Coverage for Children Aging Out of Foster Care
  - Makes mandatory the current state option to extend Medicaid coverage up to age 26 to foster children who have aged out of the foster care system, effective 2014. Children aging out of the foster care system face many challenges, including finding quality, affordable health insurance.
• Initiatives to Address Childhood Obesity
  - Provides $25 million in funding for the Childhood Obesity Demonstration Project, which was established through the Children’s Health Insurance Program (CHIP) legislation signed by President Obama. The Secretary of Health and Human Services will award grants to develop a comprehensive and systematic model for reducing childhood obesity.
  - Requires the Secretary to provide guidance to States and health care providers on preventive and obesity-related services available to Medicaid enrollees and requires each state to design a public awareness campaign on such services.

• Preventive Care for Better Health
  - This year, requires new plans to cover prevention and wellness benefits and exempts these benefits from deductibles and other cost-sharing requirements. This will help ensure that all children have access to free preventive services.
  - Invests in prevention and public health to encourage innovations in health care that prevent illness and disease before they require more costly treatment. Preventive care is a key first step towards the development of a healthy and long life, yet 32 percent of kids are overweight or obese, putting them at risk for conditions such as diabetes and heart disease.
• Expands Coverage to Improve Access to Care
  - Provides health insurance choices through state-based health insurance Exchanges to families without job-based coverage and provides tax credits to those who can’t afford it. Expanding insurance to all children will enable them to access needed care which is proven to enhance their development and learning, laying the foundation for a healthy life. Children who are uninsured have decreased access to well-child care, immunizations, basic dental services, and prescription medication.
• Lowers Health Care Costs
  - This year, eliminates all lifetime limits on how much insurance companies cover if beneficiaries get sick and bans insurance companies from dropping people from coverage when they get sick. The Act also restricts the use of annual limits in all new plans and existing employer plans this year, until 2014 when all annual limits for these plans are prohibited. Two-thirds of middle class families with access to employer-based coverage said their child remained uninsured because they could not afford the health plan. These reforms will help reduce health care costs for families and help to ensure more children are insured.
  - Going forward, plans in the new Health Insurance Exchanges and all new plans will have a cap on what insurance companies can require beneficiaries to pay in out-of-pocket expenses, such as co-pays and deductibles.

Greater Choices to Meet the Needs of Children

• More Affordable Choices
  - Creates state-based health insurance Exchanges to provide families with the same private insurance choices that the President and members of Congress will have, including multistate plans to foster competition and increase consumer choice.
• One-Stop Shopping - Putting Families in Charge
  - Provides standardized, easy-to-understand information on different health insurance plans offered in a geographic region so Americans can easily compare prices and health plans and decide which quality, affordable option is right for them and their children.
• Insurance Security
  - Ensures that children have access to affordable child-only health insurance policies, regardless of whether their parents change jobs, leave a job, move, or get sick. Parents should be able to provide health coverage for their children regardless of their job situation.
• Extends Dependent Coverage
  - This year, allows young adults to stay on their parents’ health care plan until age 26. (This applies to all plans in the individual market, all new employer plans, and existing employer plans if the young adult is not eligible for employer coverage on his or her own. Beginning in 2014, children up to age 26 can stay on their parent’s employer plan even if they have an offer of coverage through their employer.)

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Providing Culturally Sensitive Care

 
by Marcia Carteret
(Copyright © 2010. All Rights Reserved.)
 
For many years, cultural factors were largely absent from health care dialogues around patient-centered care and medical home initiatives. The current strong emphasis on cultural factors in medical care mirrors the rapid demographic changes in this country, and cultural competency has now become a favorite buzzword of policy makers, researchers, medical educators, and health care providers. The term cultural competency is most often used, but there is also debate about its applicability; its detractors say the word competency suggests one is either competent or incompetent, which in turn points towards a kind of pass/fail attitude that necessitates measurement. Measurement, however, follows being able to define and codify "competency" - which most of us would agree is a work still in process. Even with CLAS Standards in place (National Standards on Culturally and Linguistically Appropriate Services) one only has to follow conversations on relevant list serves to see that people are still debating what it means to be culturally competent. The CLAS standards are primarily directed at health care organizations, and though individual providers are also encouraged to use the standards to make their practices more culturally and linguistically accessible, the standards contribute little to the challenges of somehow measuring individuals' cross-cultural knowledge, skills, and attitudes.

What Is Culturally Sensitive Care?
 
As a cross-cultural communications instructor, I prefer the term culturally sensitive care, defined as an extension of patient centered-care that includes paying particular attention to social and cultural factors in managing medical encounters with patients from very different social and cultural backgrounds. In practice this boils down to giving health care providers a set of tools - questions and skills for negotiation based on cultural knowledge - which they can incorporate into their interactions with patients from diverse cultural backgrounds. Examples include finding out about the patient's history of present illness, their health beliefs and use of alternative treatments, their expectations of care, and any culturally-based family dynamics that guide decision-making processes. The literature supports the fact that it is important for physicians to not only be aware of cultural factors, but to demonstrate their ability to manage and negotiate them in order to improve health outcomes.

A basic premise of culturally sensitive care is that health care professionals must be able to recognize the client's culture, their own culture, and how both affect the patient-provider relationship. The following are key in addressing this important premise:

• Everyone has a culture.
• There is an American medical culture and it is very different from many of the cultures that our patients and their families come from.
• We need to understand where our American medical culture differs from other cultures in significant ways that impact communication and influence health outcomes for patients.
• Resistance to cultural difference is part of being human, and reactions to cultural difference are automatic, often subconscious, and can have strong influence on the patient-provider relationship.
• A provider's culture is influenced by his/her own personal values and beliefs, as well as those of the western medical culture.
• A provider's ability to communicate effectively in cross-cultural interactions is greatly enhanced by his/her grasp of cross-cultural communication skills.
• Culturally sensitive care requires a broad understanding of how culture affects health beliefs and behaviors.
• Providing linguistically appropriate care requires being able to assess the need for interpreters in the clinical setting and interact with interpreters effectively.

Understanding Your Own Culture
 
"In all affairs it's a healthy thing now and then to hang a question mark on the things you have long taken for granted." -- Bertrand Russell
 
Self-reflection is crucial to the cross-cultural learning process. Without understanding that everyone has a culture, and that knowledge of one's own culture is crucial, we have a tendency to reduce learning about culture to a manual-based approach, applying lists of dos and don'ts too rigidly and thereby stereotyping. Self-reflection begins with gaining knowledge about dimensions of culture and learning to apply these informed generalizations to our own culture. We thus develop a baseline for making effective comparisons about cultural differences and understand better why we respond in different situations the way we do.
 
Western Medical Culture
 
For American health care professionals, knowing about one's own culture is inseparable from knowing Western medical culture. In American culture, a person's life work informs their identity to such a large degree it sometimes seems that the credo should be "you are what you do." Some of the core values of Western medical culture are caring, empathy, truthfulness, promoting health and autonomy, and respecting an individual's choices. It is important to recognize that the health care system in the United States and some other Western countries assumes the autonomy of the patient, as seen in the Patient Self Determination Act which secures this right legally for all patients in the U.S. However, the applicability of this act to patients from various cultural backgrounds has often been debated. (Refolo 1992, Ersek 1998). In collectivist cultures, the good of the individual is often so enmeshed with the good of the family or in-group that family members may have a greater say in health care decisions than the patient does in some circumstances. For example, in many countries, family members may become very upset if a physician reveals bad news directly to a patient. Thus, physicians will not value truth-telling in the same way American doctors do because it would be culturally appropriate for them to withhold negative information from patients, especially terminal diagnoses. Even in the United States, families of certain cultural backgrounds may be more likely to prefer this approach (Blackhall et al. 1995). Some Navajos, for example, may consider it inappropriate to make mention of any negative future events because voicing them is akin to wishing them to happen.

Truth-telling is a good example of how differently people from individualist and collectivist cultures value the role of physicians. This is also a great example of why self-reflection is crucial. A physician who understands that his/her own expectations and behaviors are based on his/her culture will be more likely to consider that families may have very different expectations. He/she will be more inclined to check things out first - for example by asking who will be involved in decision making. The literature shows that patient-provider relationships are enhanced by bringing critical questions to the surface, such as: Who have you asked for help/advice about this health problem? How, and by whom, are decisions made by your family about health care? Who should be present for support or to help in decision-making? These and other questions will be explored in greater depth in upcoming newsletters.

As we begin the second year of cross-cultural communication workshops, it is important for us to hang a key question mark of our own. Why are we dedicating time to becoming more culturally aware, sensitive, and responsive? Hopefully we aren't just jumping on the proverbial cross-cultural bandwagon, directed by CLAS Standards and the extensive literature supporting cultural competence in health care. In presentations for over sixty private pediatric practices, the anecdotes and conversations shared by attendees are the best indication that the answer to this question lies in the personal dedication of individuals helping kids and families every day.
 
References
Michael A. Refolo, The Patient Self-Determination Act of 1990: Health Care's Own Miranda, 8 J. CONTEMP. HEALTH L. & POL'Y 455, 467-68 (1992).
Leslie J. Blackhall, MD et al, Ethnicity and Attitudes Toward Patient Autonomy. JAMA. 1995;274(10):820-825.The Elements of Providing Culturally Sensitive Care

Marcia Carteret, M.Ed.
Instructor, Department of Pediatrics
University of Colorado School of Medicine
Director of Cross-Cultural Communications for Colorado Children’s Healthcare Access Program

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Developmental Screening for Children Covered by Medicaid

 
Screening tools are available in Colorado to help primary care providers improve the identification of children with developmental delay by using a highly effective standardized screening test. Practices that provide standardized developmental screening at preventive care visits for Medicaid children can bill for this service and will currently be reimbursed an additional $36.50 for this screening.

Using only clinical impressions rather than formal screenings leads to under-detection and decreases the likelihood of a child receiving early intervention services.  National studies show that only 30% of children with disabilities are detected before school entrance.” (AAPCOP Policy Statement, July 2006).  Based on Colorado’s current population, potentially 40,000 infants and toddlers in our state have disabilities, but only 6,000 children from birth to three in Colorado were referred for early intervention services last year (Part C, Colorado Department of Human Services, 2006). This raises the concern that a significant number of children are not being identified and are missing the opportunity for early intervention services during these crucial first few years of life.

In order to promote early identification of developmental concerns, the use of a standardized screening tool that meets a threshold of 70% sensitivity and specificity is now recommended at well child visits for children birth to six years of age (AAPCOP Policy Statement, July 2006). The perceived barriers to screening in practices include: time, staff and inadequate reimbursement.

While there are several valid and standardized developmental screening tools available, the Ages & Stages Questionnaire (ASQ) was selected by all of the practices participating in the Colorado pilot based on its diagnostic elements and practical application.  Participating primary care offices identified several advantages of using the tool and integrating developmental screening into their practice.

Providers’ Perspectives: Advantages to Using a Standardized Developmental Screening Tool

• Time efficient – The ASQ utilizes a questionnaire completed by the parent in the waiting room or an exam room
• Supports anticipatory guidance - Serves as a talking guide with parents, identifying a child’s strengths as well as things the child is not doing yet
• Practical – Scoring takes 1-2 minutes and can be done by paraprofessionals
• Cost-efficient – The tool is affordable and the parent questionnaires may be photocopied for on-going use; practices can bill for reimbursement 
• Valid and reliable – helps to accurately identify when further diagnostic assessment is recommended

Screening Tools:
Colorado does not mandate which tools providers use in their offices.  Payment for a developmental screening, however, DOES require the use of a nationally recognized tool. Although the ASQ is highly recommended, several other standardized developmental screening tests are acceptable to state Medicaid and qualify for the Developmental Screening reimbursement.  Please reference the Birth-5 Developmental Screening and Assessment Instruments link on the HCPF website at:

http://www.colorado.gov/cs/Satellite?c=Page&cid=1218622605039&pagename=HCPF%2FHCPFLayout
OR http://www.nectac.org/~pdfs/pubs/screening.pdf

CLICK HERE to download the long list of accepted developmental screening tools
OR visit www.colorado.gov for full version document

Additional References:
http://www.dbpeds.org/
http://www.earlychildhoodconnections.org/
http://www.abcdresources.org/
http://www.developmentalscreening.org/screening_tools/
http://www.denverii.com/

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Practice Manager’s Corner - April

Kevin Heckman

Medicaid PAR Hotline
Providers can call to check on the status of Preauthorization Requests. 
This service does not provide assistance with PAR completion or submission.
The number is 1-866-956-9409

New Bi-Lingual Medicaid ID Cards
Beginning June 1, 2010 the Department will begin issuing Medical Identification Cards with a new look. The new cards will be bilingual – English and Spanish – and more informative.
These new cards do not replace cards issued before June 1, 2010, therefore, please accept both versions.
For more information, please contact Roberta.Lopez@state.co.us

National Health Reform and Colorado
National health reform does not negatively impact our goals outlined in the CO Health Care Affordability Act. We are good to go and will move forward with all efforts including the expansions to Medicaid parents to 100% FPL and CHP+ up to 250% FPL to be implemented on May 1, 2010.
Note: It is important to remember that all program implementations are dependent upon the Centers for Medicare and Medicaid Services, or CMS, approval of the hospital provider fee. We expect to receive approval the first week of April.

Colorado PEAK Online Eligibility Overview
http://www.colorado.gov/benefits/
In addition to growing client enrollment rates in the Colorado Benefits Management System (CBMS) programs, Colorado is experiencing more widespread use of e-communication and Web-based interactions, as well as a demand for increased client and community outreach capabilities from its public service agencies. In order to meet these diverse needs head on, the State of Colorado has begun work to implement revolutionary enhancements that will allow it to continue to improve the lives of its citizens.
The Colorado Program Eligibility and Application Kit (PEAK) is the flagship tool that will allow the State to meet these new service needs. PEAK is a Web-based portal designed to provide clients and community partners with a modern and easily accessible tool to apply for public assistance benefits. It currently allows new CBMS clients to screen themselves for potential program eligibility and allows our existing clients to check on their benefits. Coming in April 2010, clients will be able to apply for benefits.
 
The Colorado PEAK also eliminates the sometimes time-consuming process of waiting on the application submission and benefits approval for clients. Instead, the Colorado PEAK creates new opportunities for benefits screening, application, and client information updates that do not require assistance from a county or state employee. In addition, care providers are able to make applications on behalf of their clients, further streamlining the application process.
 
The Colorado PEAK puts control of benefits applications back in the hands of the clients and increases client self-sufficiency. Through this, the State of Colorado is able to ensure the CBMS performance is being enhanced to meet increasing and changing client needs, is able to improve customer service, and is able to improve statewide accountability for public assistance benefits.
 
Administration and Prior Authorization of Synagis ® Immune Globulin
Palivizumab (Synagis®) is a preparation used for passive immunoprophylaxis against respiratory syncytial virus (RSV) in high–risk infants.
To determine if prior authorization is needed for services administered in a physician’s office, please see below.
Additional information and details on this policy is available in the April 2010 Provider Bulletin Medicaid Program News and Updates (B1000282 - 04/10). 
Additional information on immunizations in general is available in the  Immunization Benefit Update (B1000276 - 01/10) bulletin, which can be found in the Provider Services Bulletins section of the Department’s Web site at http://www.colorado.gov/hcpf... For additional questions, please contact Christy Hunter at christy.hunter@state.co.us.

Synagis Administered in Physician Office

1. Client is under age 2 at start of current RSV season or at time of the first injection for current RSV season, and meets one of the following:
   • Diagnosis of Chronic Lung Disease and have had one or more of the following clinical needs during previous 6 months: 
     • Supplemental oxygen 
     • Regular use of inhaled or oral bronchodilators 
     • Recent use of corticosteroid therapy 
     • Regular or intermittent use of diurectics to treat pulmonary disease 
   • OR diagnosis of interstitial lung disease and/or new molecular disease which impacts pulmonary function 
   • OR diagnosis of congenital heart disease and meets any of the following criteria: 
     • Receiving medication to control congestive heart failure (diuretics, antihypertensives) 
     • Suffer moderate to sever pulmonary hypertension 
     • Suffer Cyanotic heart Disease 
   • OR diagnosis of hemodynamically significant heart disease defined as having one or more of the following: 
     • Infants receiving medication to control congestive heart failure 
     • Infants with moderate to severe pulmonary hypertension 
     • Infants with cyanotic heart disease 
   • OR under 6 months of age, born between 29 and 32 weeks gestation 
   • OR under 12 months of age, born at 28 weeks gestation or younger 
   • For the above conditions, a maximum of five monthly doses is recommended. For below, a maximum of three monthly doses is recommended or until the child reaches 3 months of age. 
   • OR under 3 months of age at start of RSV season, born between 32 and 35 weeks gestation and meets one or more of the following risk factors:
     
     • Currently attends day care;
     • Has a sibling younger than 5 years of age; 
     • Congenital abnormalities of the airway; 
     • A neuromuscular condition that compromises handling of respiratory secretions.
     For all of the above, no Prior Authorization Required - Do Not Submit PAR
     Physician provides Synagis and submits claim on CO1500 paper form or as an 837P transaction
2. Client is age 2 or older at the start of each RSV season but physician believes that client requires Synagis
   Prior authorization is required
   Physician must submit:
   • Prior authorization form #10013 (US Bioservices form not acceptable) and
   • Letter of medical necessity

The PAR form can be found at colorado.gov/hcpf >Providers > Provider Services > Forms > Prior Authorization Request Forms
Submit to PARS. P.O. Box 30, Denver, CO 80201-0030

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Colorado Department of Health Care Policy and Financing
Efficiencies and Cost-Containment Initiatives
March 2010

The mission of the Department of Health Care Policy and Financing is to improve access to cost-effective, quality health care services for Coloradans. Since 2007, Governor Ritter, the Department and the General Assembly have implemented an approach to health care reform that is strategic, incremental and system-wide so that every Coloradan can access high-quality, affordable health care. The results of this approach are the implementation of many strategies that improved access to health care; created efficiencies; defined consumer value for the dollar; and promoted transparency to the taxpayer.

• Preferred Drug List established by Executive Order to better manage the pharmaceutical benefits for Medicaid clients, using objective, scientific evidence to determine the efficacy of medications and to create a rational formulary for Medicaid clients. The use of the list and the aggressive negotiation of rebates from pharmaceutical companies are saving the state over $9 million per year.
• Long-Term Care Partnership launched to ensure older Coloradans have access to long-term care services when they need them, and provides an alternative to using Medicaid as their only resource for long-term care. The program has helped more than 6,000 middle-income Colorado families purchase affordable, quality long-term care insurance. 
• Medical Homes for Children established standards for providers to ensure children have access to preventative care, coordination of services, and 24/7 phone consultation. The state is saving money and improving care for children by avoiding unnecessary use of emergency departments for services that should be provided in primary care settings. Currently, 236,000 children are served in medical homes. 
• Colorado Regional Integrated Care Collaborative is a program designed to better serve high-need/high-cost Medicaid clients. Health plans provide robust care-coordination and manage the utilization of services. Savings are found through avoiding unnecessary hospitalizations and better coordinated care that reduces duplication of services. 
• PACE programs that coordinate services between Medicare and Medicaid were expanded to eight sites, allowing 2,000 elders to live at home and in their communities instead of in nursing facilities. An expansion is planned for 2010. 
• Emergency Room Diversion projects were funded in two communities with a federal grant. The projects are designed to educate Medicaid clients regarding inappropriate use of emergency rooms when primary care providers are available to serve them. Thousands of individuals in these two communities have since scheduled visits with primary care clinics. 
• The Benefits Collaborative is a Department-led initiative for defining the amount, scope and duration of each Medicaid benefit. This effort will save the state money by ensuring that all benefits offered are medically necessary and consistent with current evidence and medical standards. 
• Colorado Health Care Affordability Act (HB09-1293) expands coverage to more than 100,000 Coloradans without General Fund by using the hospital fees to draw down federal Medicaid matching funds. The combined $1.2 billion will support Medicaid and CHP+ expansions and will be used to improve hospital reimbursement. Covering more of the uninsured reduces the amount of uncompensated care in the health care system, and reduces the amount of cost-shifting of that care that is passed on to individuals with insurance. 
• Program Integrity activities identify potentially excessive or improper utilization, or improper billing to Medicaid by providers. These efforts recover approximately $8 million per year. 
• Benefits Coordination is designed to recover costs for medical care paid for by Medicaid from other insurance plans, trusts, estate recoveries, and recovering any payments to clients who were discovered to be ineligible for Medicaid. The Department recovered $45 million of Medicaid payments from estate recovery efforts. 
• Health Information Technology is a key tool in improving health outcomes and reducing unnecessary expenditures in the health care system. The Department is partnering with CORHIO, the statewide entity establishing guidelines and developing health information exchanges, to develop the tools for providers to exchange data and information about Medicaid clients. This will save the state money by allowing providers to talk with one another through secure internet or email capabilities, sharing information about client tests and treatments that will avoid duplication of services, repeated tests, and the use of inaccurate information that leads to medical errors. 
• Smoking Cessation is an important tool for improving health outcomes and reducing Medicaid costs associated with tobacco-related illnesses. Medicaid coverage was expanded to provide clients access to additional medications to help them quit smoking successfully. 
• Medical Errors, or serious reportable events, will no longer be covered by Medicaid as a result of Executive Order D 006 09. This policy results in improved patient safety, decreased Medicaid costs and saves taxpayers money. 
• Avoidable Hospital Readmissions that occur within 24 hours of discharge for a related condition will no longer be reimbursed by Medicaid. This policy will encourage better patient support during and after a hospital discharge and save taxpayers money. 
• Quality Incentive Payment Programs were adopted to provide financial incentives to nursing homes to provide higher quality services, and will be implemented with hospitals as well. A certain portion of the payment will be directly related to the achievement of quality and outcome goals. 
• Prior Authorization is an important tool in managing the utilization of high cost benefits. Medicaid now requests all outpatient clinics obtain prior authorization for non-emergent CT, non-emergent MRI and all PET scans. Justifying these non-emergent services ensures necessity and saves taxpayers money. 
• The Nurse Advice Line is being aggressively marketed to Medicaid clients as a way to reduce unnecessary use of emergency rooms. The toll-free number is now on Medicaid identification cards, in enrollment packets, and in client correspondence. The Department sent letters to clients who visited ERs more than six times, giving them the toll-free number and scheduling many of them for visits with primary care providers. The number of calls to the line increased by 300% in 2009. 
• The Accountable Care Collaborative will save the state approximately $14 million per year by holding regional organizations accountable for delivering high-quality, patient-centered, coordinated care to Medicaid clients using community-based care coordinators. 
• CHP+ at Work will be expanded, allowing the Department to provide coverage to more children through their parents’ insurance. This keeps families in the same plan, and allows the Department to pay premiums for children instead of enrolling them in a public plan. 
• Three-Share Community Projects are health coverage programs that bring together employers and workers without coverage, with community providers offering direct services to those workers. Everyone shares in the cost – the employer, the employee and the community so individuals get good, basic primary care services. The Department will support the expansion of the project in Pueblo and expand to the San Luis Valley. This expansion will be accomplished with $761,000 from a five-year federal grant. 
• The Center for Improving Value in Health Care will establish an all-payer claims data based, giving providers and consumers’ information about the costs and quality of health care provided throughout Colorado. Consumers will have transparency into the costs of services, and be able to plan for out-of-pocket expenses associated with their health care. 
• Public Health and Population Health Initiatives can save the state and other payers’ money by focusing on keeping the overall population healthy. The Department will be partnering with Baby and Me - Tobacco Free – a program that combines smoking cessation support specific to pregnant women with the incentive of free diapers to help motivate the women to stay smoke-free during the first months of the baby’s life. The Department will be promoting 5 Alive! – a collaborative, community-wide initiative to provide a supervised wellness program to Colorado 5th graders who have limited access to healthy lifestyle choices for fitness and nutrition. The Colorado Behavioral Healthcare Council will assist the Department to survey behavioral health providers on their current health promotion activities and interventions; identify improvement areas; and implement and evaluate needed health promotion and wellness interventions. 
• Veterans in the Veterans Affairs Health Care System connects eligible Colorado veterans with benefits for which they are eligible but of which they have not yet taken advantage. By working with Veterans Affairs to establish regular care for Colorado’s veterans, the high costs of emergency care can be avoided while maximizing the federal dollars contributed to the VA program. 
• Health Insurance Buy-In Program will enroll an additional 100 new clients for FY 2009-10. The program generates savings by paying the premiums, deductibles, and co-insurance for clients who would otherwise be utilizing higher cost services. The clients can continue seeing their physicians of choice thus maintaining continuity of care. 
• Fluoride Varnish Treatments allow the Department to avoid costly dental and medical procedures by providing children up to age 6 with effective, preventive dental care though fluoride varnishing. 
• Manual Pricing of DME, Injectibles, and Medical Services removal allowed the Department to automatically set reimbursements a percentage of Medicare while ensuring that for goods and services where no Medicare rate information exists, rates were set using the Department’s average paid, other states' Medicaid average paid, or the commercial average paid rate. By developing an automated reimbursement rate setting methodology, the Department ensures that it is always generating value for medical goods and services by reimbursing at appropriate prices. 
• Evidence-Guided Utilization Review will divert clients away from inappropriate medical care by providing reviews of services received and reimbursing only those services that are medically necessary. The Department’s designated Quality Improvement Organization (QIO) will expand the scope of services currently reviewed, providing additional savings while also identifying situations and allowing for intervention where utilization patterns are not in the best interest of our clients. 
• Coordinated Payment and Payment Reform will streamline payment processes, enhance recovery efforts and provide for proactive integration of care while expanding the application of performance-based payment structures which incentivize desired outcomes. Physician Payment Reform and Waiver Rate Reform will create payment plans based upon health outcomes, allowing the Department to purchase better health rather than to simply purchase medical services.

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Healthy Homes / Healthy Kids

A Project to Improve Housing For Children With Asthma

We are pleased to announce a cooperative project between National Jewish Health and Northeast Denver Housing Center sponsored by HUD that will help identify and fix or remediate asthma triggers in the homes of children living in Northeast Denver.  In addition to helping families this project examines the efficacy of a low-cost, sustainable home assessment and intervention system for indoor asthma triggers.  Past research has shown that environmental factors within homes can significantly impact the asthma symptoms of the people who live within those homes.  The purpose of this study is to evaluate home environmental factors and to determine if knowledge of potential hazards, combined with educational intervention and possible remediation will reduce the impact of the home environment upon children with asthma.

We are looking for:

• Families who speak English or Spanish and have a child under the age of 12 with asthma or recurrent wheezing;
• Families who live in one of the following neighborhoods:
  Globeville, Elyria Swansea, Five Points, North Capital Hill, Cole, Whittier, Skyland, Northeast Park Hill, City Park West, City Park North and Clayton

For participating, families receive:

• A detailed report about any problems we find and what you can do to improve these.
• A free vacuum cleaner and other household cleaning and safety supplies.
• The possibility of free professional assistance in repairing problems.                    

Each family enrolled in the project will receive 2 home visits, approximately 9 to 12 months apart.  During the initial home visit the project staff will ask the participant some questions about their home environment and their child’s asthma.  They will also conduct a visual survey of the participants home and will collect dust and air samples.  This visit will last about 3 hours and the participant will be given approximately $150.00 worth of cleaning supplies, including a vacuum cleaner.

Shortly after the first visit we will mail the parent the results of what we found including recommendations for how conditions in the home might be changed in order to improve your child’s asthma.  If the parent agrees, the results of these tests will also be sent to you and the child’s health care provider.  Project Staff will also speak with the parent over the phone in order to go over the results and the recommendations made.   Depending on the problems identified, families may be offered up to $5000 in professional remediation provided through the Northeast Denver Housing Center.

We hope that you will consider sharing information about this project with eligible families within your practice.

For more information please call Mike Vandyke, PhD at 303-398-1034 or Andres Diaz at 303-398-1447.

CLICK HERE to download flyer in English and Spanish

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Cavity-Free at Three

Cavity Free at Three is a statewide effort aimed at improving oral health in children and pregnant women.  We are working with CCHAP to offer our program model to interested participants.  Recent Medicaid guidelines allow primary caregivers to provide oral health counseling along with fluoride varnish application and receive reimbursement for these services.  In order to participate, the medical provider as well as staff members involved in this provision of care should complete online training through the Smiles for Life Curriculum.  

Simply visit  http://www.smilesforlife2.org, and complete Module 2:Child Oral Health and Module 6: Fluoride Varnish.   After the online process is completed, we plan a coordinated effort for site visit based training opportunities offering hands on demonstrations as well as follow up and support of our program.

We are in the process of coordinating training opportunities throughout the state of Colorado beginning early 2010.  This will allow for representatives from your group to attend trainings in your area.  If you are interested in hosting a training, or learning more about Cavity Free at Three opportunities, please contact Anita Rich at rich.anita@tchden.org.  If you have questions specific to our program, please contact karen.savoie@ucdenver.edu or visit  http://cavityfreeatthree.org. Thank you.

Announcements:

Thank you to Pediatric Partners of Glenwood Springs, particularly Brian McGill, for coordinating a Cavity Free Training on February 16th.  15 people attended.  That is a great turnout.  

More training is scheduled for March. March 18th in Durango hosted by Pediatric Partners of the Southwest and on March 26th hosted by Miramont Family Medicine in Ft. Collins.

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How to Refer Infants and Toddlers for Early Intervention Services

Bill Campbell

This is a quick reminder that for children suspected of having developmental delays, the referral resources depend on the age of the child.   Refer  infants and toddlers to Early Intervention Colorado if they are suspected to have significant developmental delays, or if they have any health conditions associated with a high probability of developmental delay.  Refer preschoolers and children not already enrolled in public school to Child Find for similar concerns.  For families whose children are already enrolled in public school, the parents have the right under special education law to request a comprehensive educational evaluation, but it’s best if they start by request a formal meeting with school staff, including the teacher, a special educator, and a school administrator.  At the end of this article you’ll find a link to a referral flow chart that outlines the decision-making process for referring children of different ages for developmental and educational assessments, but the following paragraphs will focus on how to refer infants and toddlers for early intervention services.

Developmental delay is common among infants and toddlers (at least 10 percent of infants and toddlers have delays in one or more areas of development).  Early intervention services have been shown to be effective in helping children with developmental delays, particularly children with autism spectrum disorders and other communication handicaps.  All 50 states have developed early intervention programs in accordance with Part C of the Individuals with Disabilities Education Act.  All 50 states also have special education procedures and services for preschoolers and school-age children.  

Colorado’s early intervention program is called Early Intervention Colorado (formerly Early Childhood Connections), or “EI Colorado” for short.  It’s designed to promote the best possible outcomes for infants and toddlers (birth up to 36 months of age) who have significant developmental delays (or health conditions associated with a high probability of developmental delay).  In order to take advantage of early intervention services during this critical developmental period, families need to know how to access them.  The following paragraphs explain this, and additional information can be found in the “Make a Referral” section at www.eicolorado.org.

While anyone – including the parents -- can refer a family to EI Colorado, primary care providers (PCPs) are the main source of referrals.   And using a standardized screening test is the most reliable way to identify children with delays.   A recent quality improvement initiative in the Denver metro area suggests that infants and toddlers are more likely to proceed through the evaluation phase if the PCP sends a referral form to the local EI Colorado program, in addition to having the family call the referral contact person there.
The PCP should inform the family that further evaluation is recommended to see if the child and family may benefit from early intervention services.  You can give the family an early intervention flier or panel card that briefly explains this, and also tells the family how to contact their local EI Colorado program.  These informational cards can be obtained for free from your local EI Colorado program office (e.g., from Denver Options for those residing in Denver), or you can order panel cards for free on the EI Colorado website (www.eicolorado.org) by clicking the “order public awareness materials” link on the home page or in the “Make a Referral” section.  You’ll find a lot of other information in the “Make a Referral” section, such as explanations of the early intervention assessment process and even links to professional medical society recommendations for the medical evaluation of children with developmental delay.

The process for having the infant or toddler evaluated begins with making a referral to EI Colorado.  The referral form should be completed by the PCP office during the visit, and the parent or legal guardian should be asked to sign the consent to release medical information at the bottom of the referral form.  You can obtain referral forms in English and Spanish for free from the EI Colorado website.  Or you can access the referral forms specific to your local EI Colorado program in the “Make a Referral” section of the website by clicking on the “Make a Referral” link and then scrolling down to the link that says: “To refer to Colorado's early intervention system click here to locate the appropriate Community Centered Board! (includes referral form)”.  You’ll then be taken to a page where you can enter or search for the specific local EI Colorado program, which will then take you to a page with that program’s contact information and links to referral forms with preprinted local program name and fax number.  I’ve found it easiest to keep preprinted referral forms handy rather than printing a form for every referral.

If the child was referred because of concerns on standardized developmental screening, please document the tool you used and fax the screening instrument along with the referral form; this will help the evaluation team understand the screening results and develop an assessment plan without repeating the screening.  I should mention at this point while the evaluations are conducted by Child Find teams from the local school districts or BOCES, the local EI Colorado programs arrange these and provide coordination throughout the process, so please refer infants and toddlers to the local EI Colorado programs directly (a service coordinator will be assigned and contact the local Child Find team within a couple of days).

Provide the family with a copy of the referral/consent form and the contact information for the local EI Colorado program, and arrange a follow-up visit for about 2 months later.  Explain to the family that a service coordinator will be assigned within a couple of days of the referral to help the family through the next steps; the developmental assessment should be completed within 45 calendar days, as well as the Individualized Family Service Plan (IFSP) if the child is found to be eligible for services (both are at no cost to the family).  Ask the family to bring copies of the IFSP and any evaluation reports.  Even though the Early Intervention and Child Find teams do not provide medical diagnoses, their findings can be important to you in helping the family understand the significance of the developmental delays and in guiding further appropriate medical evaluations.

Speaking of medical evaluations, you may have already initiated some when you first became concerned about possible developmental delays.  For example, children with language delay should be referred for formal audiology evaluations.  You don’t need to wait for audiology or other medical evaluations or treatments to be completed before referring to EI Colorado for early intervention evaluations and services.  The link to the referral flow chart at the end of this article illustrates the parallel processes for medical and developmental evaluations.  Professional medical society recommendations during recent years have offered specific recommendations regarding the medical evaluation and follow-up by primary care physicians/clinicians for children with developmental delay, cerebral palsy, and autism spectrum disorders.

And speaking of developmental evaluations, you can usually wait for the results of the early intervention or special education evaluations before referring for diagnostic medical developmental evaluations, such as those done in the Child Development Unit at The Children’s Hospital.  But if an autism spectrum disorder is suspected, then you should refer simultaneously to EI Colorado (for early intervention services) and to a medical center or clinic with special expertise in autism spectrum disorders (for the diagnostic medical evaluation).  The referral flow chart below gives other examples of where to refer children for medical or behavioral evaluations and treatment.

Click here to view the referral flow chart

I hope this information is helpful to you in getting early intervention services for infants and toddlers as soon as possible, and in getting preschoolers and school age children the help they need.

Please feel free to call me with any questions at 720-777-6632, or email me at Campbell.william@tchden.org.

Also see these two web sites for more detailed algorithms

The link for the 0-3 year-old flow diagram: click here
The link for the 3-5 year-old flow diagram: click here

These are the referral forms that are used state wide for Early Intervention.

• English - click here
  
• Spanish - click here

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The Provider Resource Helpline Helps Your Special Needs Children:
Identify and Access All Resources
Assists with Care Coordination

          The American Academy of Pediatrics has promoted the concept of providing a medical home for children with special health care needs for over a decade.  At a recent focus group of family physicians and pediatricians discussing medical home, primary care providers said that finding the available resources and coordinating care for children with multiple problems was the most challenging of the roles of a medical home.  
          The Provider Resource Helpline is a service created to address this need through a collaboration among CCHAP, Family Voices, and the Colorado Department of Health Care Policy and Financing (HCPF), which administers Medicaid and CHP+.  Family Voices of  Colorado is a chapter of the national, grassroots organization composed of families and friends who care for and about our children with special health care needs.

Provider Resource Helpline
Helping care for our children with special health care needs

Information for families
Valuable community resources
Care coordination

1.877.731.6017

The Colorado Provider Resource Helpline is here:

• To give providers information and access to valuable community resources for children with special health care needs.
• To provide case management and care coordination services to families.
• To identify shortages in services/barriers through the data collected.
• To provide family-centered programs, training and education.

When Calling, Please Have the Following Information:

• The PCP name and office phone and fax information.
• Name and date of birth of patient.
• Medical condition / disability of patient.
• Resource question or service need of patient/family.
• Family Contact information, if the provider wishes us to follow up directly with the family.

If the helpline can answer your question immediately, you can provide the information to the family while they are still in the office.  If we are unable to answer immediately, we will contact you with an answer as soon as possible following the patient’s visit (via phone, fax, or email). 

Download Flyer

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Medical Home Certification

Around 50 of the 150 pediatric and family practices that CCHAP currently works with are in the process of obtaining “medical home certification.”    The Colorado Department of Health Care Policy and Financing (HCPF), which administers Medicaid in Colorado, is directed by  Senate Bills 07-130 and 07-211 to document that children on Medicaid receive care in a quality medical home.  So, HCPF is asking practices that are receiving the enhanced reimbursement (as a CCHAP – affiliated practice) to obtain Medical Home Certification to document the quality of the medical home they provide to children on Medicaid.  Practices that have affiliated with CCHAP in the past 8 months have already begun the certification process.  The remaining CCHAP-affiliated practices will be asked to begin the certification process very soon.  

Medical home certification is a three step process.  The CCHAP orientation is step one.  The following are the two steps needed for medical home certification for practices that were oriented in the past and are already receiving the enhanced reimbursement.  Each CCHAP-affiliated practice will be asked to:

• Conduct a self-assessment survey of practice staff and providers called the Medical Home Index.  This brief survey seeks to determine your perception of how well you are doing in providing a medical home.  The survey also will be given to some parents in your practice.
• After reviewing your survey results, you will be asked to select some aspect of “medical home-ness” to improve using a quality improvement process.  CCHAP staff is available to coach you through the quality improvement process if you wish and we have QI projects already prepared for you to implement easily in your practice if you wish.  You may already have QI projects going, which will likely meet this objective.

Medical Home
The American Academy of Pediatrics and the American Academy of Family Practice have promoted the concept of a medical home for many years now.  A recent combined statement by the two academies reaffirmed their support of the concept.  The Academies believe that all children should have a medical home where care is accessible, family-centered, continuous, comprehensive, coordinated, compassionate and culturally effective.  For a reminder of the American Academy of Pediatrics and the American Academy of Family Medicine description of a medical home for children, click here. 
And if you want someone to come to your office to present a more description of what a medical home is and does, please contact: Anita Rich (Rich.Anita@tchden.org) or Angie Goodger (angela@cchap.org) for more information.

Medical Home Index
Starting in April 2009, recently oriented CCHAP practices began the process of Medical Home Certification.  The Medical Home Index is completed at a group meeting of your practice with as many of the practice staff and providers as possible. During this meeting the group will complete a Medical Home Index self-assessment, discuss how each indicator rated relates to a quality Medical Home.  The facilitator will conduct informal interviews of families coming to your practice that day asking them to assess the practice’s medical “homeness.”  For a look at the medical home index, click here.

Quality Improvement Projects
Within a few weeks after the practice takes the MHI, you will be contacted by a Quality Improvement Coach with CCHAP. At that time, you will receive your Medical Home Index results, as well as guidance as to how to interpret the results. HCPF asks that you select an element of being a medical home that your practice wishes to work on.   The Quality Improvement Coach from CCHAP – at no cost to your practice – is available to help you decide what your practice would like to work on, develop strategies for making the changes you want to make, and measure the effectiveness of the resultant changes.   

The higher reimbursement practices receive for preventive care is the reward for your practice’s commitment to providing a quality Medical Home for children on Medicaid.

AAP and AAFP Board Certification for pediatricians and family physicians
Both the AAP and the AAFP require that all physicians, when they recertify, develop a quality improvement project in their practice as part of their recertification.  So, CCHAP is helping you obtain both professional board certification and Colorado Medicaid medical home certification.

For more information
Shortly, we will be expanding the Medical Home Certification process to all CCHAP practices.  More information will follow. You may also contact Anita Rich (Rich.Anita@tchden.org) or Angie Goodger (angela@cchap.org) for more information.

Quality Improvement Coach
Your CCHAP Quality Improvement Coach is Angie Goodger. Angie holds masters degrees in Public Health and Healthcare Administration.  Angie comes to us from Minnesota where she previously worked as a home healthcare manager. Angie is very excited about working with your practice using Quality Improvement methods to work on those issues you want to address.

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The Colorado Pediatric Postpartum Depression Screening and Referral Toolkit

Developed by Brian Stafford, MD, MPH
Medical Director, Perinatal Mental Health Program, The Children’s Hospital

Click here to download the complete toolkit to enable a primary care practice
to recognize and refer women with post-partum depression.    

Why should every pediatric and family practice implement this toolkit?

•  Postpartum depression is a serious medical and psychiatric illness and a significant health concern.
• Approximately 12% of all new mothers develop symptoms consistent with a major depression in the post-partum period
• If left untreated, half of these mothers, about half will continue to have symptoms that last greater than1 year.
• These symptoms include sadness, lack of energy and pleasure, irritability, guilt, anxiety, as well as thoughts of wanting to harm the infant.
• Several lines of research have shown that post-partum depression has significant risk for the child’s cognitive, social, and emotional development and may impact school readiness.
• In addition, the depressive symptoms lead to difficulties in the mother-infant and parental relationship.
• The depressive symptoms are also associated with excessive urgent care and emergency room visits as well as missed scheduled routine pediatric visits.
• Providing pediatric anticipatory guidance to a depressed caregiver does not change any parental behaviors in regard to safety, sleep, nutrition, reading, and interaction.
• Pediatric care providers of infants are in a strategic position to screen and refer depressed mothers for behavioral health evaluation and support.
• Pediatric provider inquiries about maternal health have been viewed as appropriate by mothers.
• Pediatricians, historically, like other primary care providers, have low rates of detecting maternal depression and few pediatricians have a systematic approach to screening for maternal depression.

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Announcing an Interactive Cross-Cultural Communications Website
Designed Especially for Healthcare Professionals

dimesionsofculture.com

 
Register now! Click the link above and get full access
with your own secure login and password!

A Website to Support On-going Training for Healthcare Professionals in Colorado

Because culture can have important clinical consequences, this website is devoted to supporting the self- development of healthcare professionals in basic cross-cultural communication competencies that impact health outcomes for patients. In place of the typical "diversity training" approach, practical communication strategies are emphasized that can be put to use immediately in private practices, clinics, and hospital settings.

An Interactive Website for Building a Learning Community
 
The content of this cross- cultural communications website focuses on reinforcing key concepts presented in cross-cultural communication trainings by Marcia Carteret. Additionally, this site presents the opportunity for physicians and staffs in multiple healthcare settings to interact with one another through threaded discussions. Because nothing can replace real life experience in the learning process, a virtual learning community will make it possible to share true stories and post useful questions while culture and medical experts facilitate discussions.
 
Website Features
 
Listed here are the pages that currently make up dimensionsofculture.com. Please note that some pages require a login and password because only select groups of healthcare professionals, including all CCHAP pediatric practices, will have full access to the “community” pages.

Public Pages

• Home Page
• Greetings from the Site Editor
• Culture Calendar- Monthly religious and cultural holidays
• Culture Quest – Information about cultural happenings in our community, as well as statewide and nationally.

Healthcare Community Pages (Login/Password Protected)

• Newsletters – Monthly articles addressing key cross-cultural communication topics written by Marcia Carteret and other guest contributors.
• Interactive Forums– an interactive on-line community dialogue between healthcare professionals about communicating with patients from different cultural backgrounds. 
• Provider Profiles– An ongoing series of profiles introducing some of the dynamic and culturally diverse doctors working in the CCHAP network of pediatric practices
• Culture Ambassadors – A panel of representatives from cultures around the globe, with a strong focus on the cultures most heavily represented across out state.

This website is designed to meet the needs of the healthcare community served by Colorado Children’s Healthcare Access Program. If you are a participating CCHAP provider or staff member and have suggestions for the website, please contact Marcia Carteret at mcarteret@gmail.comor 720-777- 3124. Your comments and suggestions will help make dimensionsofculture.com an effective tool for learning and community building.

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INTRODUCING THE CCHAP QUICK REFERENCE LINK!

Do you need to know the one telephone number to call for a Medicaid mental health referral?  Want to reach the CCHAP social worker?  Need help in finding resources for a special needs child?  Having trouble remembering all of the 14 support services CCHAP provides for your practice?    We have a quick reference link for your desk top!  For these things and many more…

Recently, our advisory group of physicians and practice administrators suggested an idea for a quick and easy way to access CCHAP affiliated resources for frequently used contacts and services.  We liked the idea and have developed a web link that will quickly access a single page that contains contact information as well as additional links to documents and web pages.  The goal is to have a computer desktop shortcut that, with just a click or two, will provide CCHAP affiliated providers and staff with the information you need, when you need it.  

Because this new tool is for you, we want it to be pertinent and efficient.  So please, if you have ideas as to how to improve on this, contact Kevin Heckman heckman.kevin@tchden.org or 720.777.6309, our Program Administrator, with your feedback and suggestions.  Thanks!

INSTRUCTIONS:

1. Click on this link http://www.cchap.org/qr/ to open the Quick Reference Link web page (Note: you can also type this address into a web browser manually).
2. In your browser window menu (upper left corner) click File>Send>Shortcut to Desktop. 
3. The Quick Reference Link is available from any computer with internet access.

Kevin C. Heckman
Program Administrator
CCHAP
720.777.6309

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All CCHAP-affiliated Practices Now Can Receive
TELEPHONE CONSULTATION ON MENTAL HEALTH ISSUES
FOR CHILDREN ON MEDICAID

Rick March is a child psychiatrist who has received grant monies to provide phone consultation regarding children and adolescents with mental health problems throughout Colorado.  He has over twenty years experience in child psychiatry and is available weekdays during regular business hours.  If you do not reach him directly, he would be able to speak with you, at the outside, by the next business day.  Dr. March is at the Mental Health Center of Denver which provides services for children who live in Denver County.  However, he may be able to arrange to see other patients outside this catchment area, possibly in your practice in very difficult cases.  He is also available to provide educational presentation for your providers on a wide variety of mental health topics.

His direct line is 303-504-1500

So, telephone consultation from a child psychiatrist for Medicaid children cared for in a CCHAP-affiliated practice is now available in all counties in Colorado.  

For Boulder and Jefferson Counties – Don Bechtold, MD – 303-432-5172
For Adams, Arapahoe and Douglas Counties – Joe Pastor, MD – 303-853- 3888
For all other counties (including Denver) – Rick March, MD – 303-504-1500

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Integrating Developmental Screening
Into a Pediatric Practice

• The Colorado Assuring Better Child Health & Development (ABCD) project has received a three year grant to provide training and technical assistance to providers to implement a “validated” developmental screening tool at well child visits for infants/toddlers birth to five.
• The ABCD project is partnering with CCHAP to provide training and support to pediatric practices to implement developmental screening.
• Medicaid will reimburse $34.00 to providers if you use a standardized, validated developmental screening test at an EPSDT visit.
• The Colorado Chapter of the AAP supports the ABCD project.
• Early detection and intervention improves outcomes.  Many delays in children’s development are missed in the first 4-5 years of life without a standardized, validated screening test. 
• The most time-efficient tool is one in which the parent completes a questionnaire.
• To comply with 2010 recertification guidelines by the American Board of Pediatrics, documentation will be required to show levels of involvement in practice improvement initiatives. By implementing the use of a “validated” developmental screening with a sensitivity and specificity rating of 70% or greater like the ASQ or PEDS, practices are taking steps to integrate quality improvement into their practices.
• What providers are saying about implementing either the ASQ or the PEDS parent questionnaire developmental screening tools:
  •  
    • It takes 1-2 minutes for an MA, LPN or RN to score.
    • It takes less than a minute of the provider’s time if the MA, LPN or RN scores the questionnaire.
    • In many instances, it reduces the length of the visit.
    • It helps providers concentrate on the concerns/priorities of the parents.
    • It reduces the number of concerns that come up as you are walking out the door at a well care visit.
    • It improves patient satisfaction.
    • It promotes positive parenting practices.
    • It increases provider confidence in decision-making for when to refer a child for further developmental evaluation.
• Eileen Auer Bennett, the Colorado State ABCD Coordinator and her team are available to assist providers in getting started. Training and technical assistance will be provided to practices to implement a standardized tool such as the ASQ or PEDS. Support will also be given to office staff on how to incorporate a standardized developmental screening tool into the current office work flow.

For more information, please contact:
            Eileen Auer Bennett
            720-333-1351
            ileanben@yahoo.com

The Ages & Stages Questionnaire (ASQ) is a well respected screening tool.  It has the best sensitivity and specificity.  It is standardized across various common minorities.   Health care providers have identified the following advantages:

• Parent completed—Parents are partners in their child’s
  assessment and intervention activities.
• Serves as a talking guide with parents identifying a
  child’s strengths as well as things the child is not
  doing yet.
• Practical—Scoring takes 1-2 minutes and can be done
  by paraprofessionals.
• Cost-efficient—May be photocopied repeatedly.
• Scoring is simple—Only three responses:
  1. Sometimes, occasional or emerging response from
     child = 5 points
  2. Yes, child performs specified behavior = 10 points
  3. Not Yet = 0 points
• If the child’s total score falls in a shaded area of the bar
  graph for any developmental area, further diagnostic
  assessment is recommended.

• Developed out of four cross-validation studies on a
  nationally representative sample of families.
• Uses parent concerns or judgments about the child’s
  development and behavioral status.
• Easy to score—two minutes to elicit and interpret.
• Enables health care providers to determine the need to
  refer and where.

Visit www.pedstest.comto view and order the PEDS tool online.

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Spanish Interpretation Training for Pediatric Practices

An assessment of each individual’s skill level will be done during a 5-10 minute phone call prior to first telephone conference/class.  Maria will contact you to schedule this initial individual telephone call upon receipt of your registration email.  A certificate of completion will be given after completion of all 6 sessions. The faculty is Maria Soto, a certified Spanish interpreter and trainer with International Language Services.

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Child Psychiatrist Available to Provide Conferences for You In your Office

Rick March, MD is a child psychiatrist at the Mental Health Center of Denver.  He is available to provide teaching on a variety of child Psychiatry topics (below) in your office.  He is also willing to discuss cases with you, as well.  Please contact him to take advantage of this wonderful opportunity.
He can be reached at Rick.March@MHCD.org

Here are some of the topics he can cover for you.

• Diagnosing Depression in Children and Adolescents
• SSRI’s and Black Box warnings
• Suicide and self-abuse
• Diagnosing Bipolar Disorder in Children and Adolescents (including differential diagnosis)
• Atypical Antipsychotics
• Mood Stabilizers and Antidepressants
• Pediatric Psychopharmacology and the FDA
• Kids with ADHD who don't get better on stimulant medication
• Psychosis in Children and Adolescents

And, remember there is a child psychiatrist on call available by phone for your Medicaid children…

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Abe Grinberg MD, FAAP MPH
   

Language as a Communication Barrier in Medical Care for Hispanic Patients

           Communication with patients and their families is essential in providing quality medical care. Cultural and language barriers create a void in the delivery of safe health care, customer satisfaction and quality of care. The public debate on how to bridge cultural and language barriers has a long history. The use of formal interpreters and translators is associated with the ability to eliminate these barriers; however, the ability to communicate directly with health professionals in a common language is associated with an increase level of trust in medical settings.

             There are 7 important points to have in mind when addressing cultural and language barriers with the Hispanic patients and their families:

1. The number of people speaking a language other than English at home and the number of Americans Limited in English Proficiency (LEP) in the United States is significant. It is expected that the total number of people in these two groups will continue to increase at a faster rate than the one of the general population in the USA. About two thirds of them are Spanish speaking individuals (₁) (₂).
2. Multiple studies document that quality of care can be seriously compromised when Spanish LEP patients need but do not get translation and interpretation services (₃) (₄).
3. Studies also document that the quality level of interpretation offered by bilingual providers and professional hospital interpreters is high. However, the quality of interpretations offered by hospital employees who are not professional interpreters, family members, relatives, friends, and ad-hoc translators are many times incorrect and of poor quality (₅).
4. Interpretation errors are common. About 60% of the errors have potential clinical consequences. Even professional interpreters commit significant errors about 50% of the time (₅).
5. Patients, who interact with a bilingual provider, frequently rate them as more friendly, respectful, and concerned when compared to those who interact with a translator or interpreter. Patients and families who are taken care by a provider who speaks their own language frequently have a more accurate recall of critical information about the encounter than those who interact with a provider who uses a translator or an interpreter(₆) (₇).
6. There are data that suggest that the length of hospital visits, the incidence of any testing, the cost per visit and the number of hospital admissions are decreased in those patients who interact with a provider who speaks their own language when compared to those providers who use a translator or interpreter during the course of the medical encounter (₈). 
7. There is evidence that courses in Medical Spanish can help health care professional achieve fluency in Spanish at the functional level and promote cultural awareness that strengthen communication skills. The promotion of such courses is associated with decreased interpreter use and increased patient and family satisfaction (₉).

          Bear in mind that Hispanics embrace people when they make an effort to speak their own language. They tend to be tolerant and have a tendency to develop relationships that are based on friendship and respect. You will make them fill comfortable and help them feel that you are concerned about their medical care.
 
          “Dele a un hombre un pescado y él comerá por un día. Enséñele cómo pescar y comerá por el resto de su vida” (Lao Tzu. Filósofo Chino).

1. 1. Flores Glenn. 2005. The Impact of Medical Interpreter Services and the Quality of Health Care: A Systematic Review. Medical Care Research and Review 62: 255- 299
2. Colorado Alliance for Immigration Reform. U.S Immigration Data, Projections and Graphs. Retrieved: October 2, 2008. http://www.cairco.org/data/data_us.html
3. Flores, Glen., Abreu, Milagros., Schwartz, Ilan., and Schwartz, MD, and Hill, Maria. (2000). The importance of language and culture in pediatric care: Case studies from the Latino community. The Journal of Pediatrics. 137 (6): 842-848
4. Flores G. Language Barriers to Health Care in the United States. NEJM 2006; 355:229-23
5. Flores G., M.B. Laws., S.J. Mayo., B. Zuckerman., M. Abreu., L. Medina and E. J. Hardt. 2003. Errors in clinical interpretation and their potential clinical consequences in pediatric encounters. Pediatrics 111: 6- 14
6. Baker, David W., Hayes, Risa., and Puebla Julia. 1998. Interpreter Use and Satisfaction with Interpersonal Aspects of Care for Spanish- Speaking Patients. Medical Care. 36(10):1461-1470 
7. Seijo, R., H. Gomez and J Frienderber. 1995. Language as a communication barrier in medical care for Hispanic patients. In. Hispanic Psychology_Critical issues in theory and research, edited by A.M. Padilla, 169-181. Thousand Oaks,Ca: Sage.
8. Hampers, L. C and., McNulthy, J.E. 2002. Professional Interpreters and Bilingual Physicians in a Pediatric Emergency Department. Arch Pediatr Adolesc Med. 156:1108-1113.
9. Suzan S. Mazo., Louis C. Hampers., Vidya T. Chande. Steven E. Krug. (2002).Teaching Spanish to Pediatric Emergency Physicians: Effects on Patient Satisfaction. Arch Pediatr Adolesc Med 156: 693-695

Course in Medical Spanish customized for pediatric care providers. Once a week for 12 weeks (2 hour class), includes also 6 month internet access to “Spanish for health care course”. Flexible schedule to accommodate participants’ preferences; Classes take place at the providers’ office for groups of 8-12 students.
$ 389 dollars per student. Includes 6 month internet access to the on line training course.
          Contact: Abe Grinberg MD (720) 748-7669.
          abe@bilingualmed.com my web-site www.bilingualmed.com

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Copyright 2010 Colorado Children's Healthcare Access Program and other entities as noted.

 CCHAP Home > Newsletter Articles > Newsletter 37, April 2010